Claim Form Application

As per the name above, I acknowledge that I am the registered owner of the motor vehicle with the registration number stated above.

Authority and Direction

I hereby authorise and direct SR Smash Solutions, in the State of New South Wales, as follows:

1. To act on my behalf as an agent/authorised representative in relation to my claim.
2. To obtain quotations, reports, invoices, photographs, and other documents to support my claim.
3. To claim damages related to repairs and hire car, negotiate, settle, and manage all correspondence concerning my motor vehicle claim.
4. To obtain an independent assessor report to substantiate my losses.
5. To retain legal representatives to act on my behalf and to be responsible for the payment of all legal costs and disbursements.
6. I irrevocably authorise SR Smash Solutions to sign on my behalf any acknowledgements or releases required to settle my/our claim, and to direct settlement cheques to be made payable to the legal representative for the deduction of fees and repair costs.
7. I acknowledge that if SR Smash Solutions decides, for any reason, to no longer act on my behalf, no fee will be payable to SR Smash Solutions.
8. I acknowledge that if I withdraw my claim without the consent of SR Smash Solutions, I will be responsible for all fees incurred, including assessment and legal fees.
9. I certify that there are reasonable grounds for proving the facts of my claim and that it has reasonable prospects of success. I acknowledge that statements may be required from me, my driver, assessor, or witnesses if the claim proceeds to litigation.
10. I release and indemnify SR Smash Solutions from any present or future claims arising from their actions taken on my behalf in relation to my claim.
11. This authority remains in effect until I revoke it in writing.
12. I declare that the above-mentioned particulars are true and correct.